Ohio Admin. Code 5160-36-06 - Program of all-inclusive care for the elderly (PACE): organization reimbursement
(A) PACE is a full-risk program in which the
PACE organization assumes all financial risk for the cost of the medical care
and services provided to PACE
participants.
(B) PACE
organizations shall receive a monthly capitated payment from the Ohio
department of medicaid (ODM) for each PACE participant enrolled in the medicaid
program including individuals enrolled in both medicaid and medicare.
(C) The amount of the capitated payment shall
be established in the PACE program
agreement.
in rule
5160-36-02
of the Administrative Code.
(D) The amount paid in accordance with
paragraph (B) of this rule represents the total maximum payment obligation of
the state administering agency to the PACE organization for the cost of medical
care and services provided to PACE
participants enrolled in medicaid including those participants enrolled in both
medicaid and medicare.
(E) The PACE
organization shall accept the capitation payment amount as payment in full for
medicaid participants and shall not bill, charge, collect, or receive any other
form of payment from ODM or from, or on behalf of, the participant, except as
permitted under
42 C.F.R. Part
460.182(c) as in effect on
October 1, 2013
2019 .
Notes
Promulgated Under: 119.03
Statutory Authority: 119.03
Rule Amplifies: 5164.02, 173.50, 5162.35
Prior Effective Dates: 03/28/2009, 07/01/2011 (Emer.), 09/29/2011, 01/01/2015
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